Category: Industry News

SHP Fall Webinar Series New Dates

SHP has added new dates and topics in our Fall webinar series, which focuses on a variety of current and bottom line-impactful  topics.

These webinars serve as a tool to educate and provide actionable takeaways for healthcare providers on real time COVID updates, QPP 2021 Rules, and Revenue Cycle best practices such as Managed Care and Provider Enrollment.  We are also pleased to have the Commissioners for both the Department of Insurance (DOI) and Department of Community Health (DCH).  So, please order in lunch as we interactively discuss such topics amongst your peers.

Visit our webinar schedule for updated information.

BCBSGA Provider Enrollment Update: Mid-Levels

Attached is a guide on how to submit for mid-levels via the Provider Maintenance Form for BCBSGA. If submission is done as an “Organization” a roster can be uploaded so it won’t be as tedious as completing a form per mid-level.  You will also find attached a list of BCBS reps for the different regions around the state that you will be able to follow up with for confirmation that these updates have been made.  We recommend you request the effective date of 9/1, even though there is no guarantee that you will receive that date.

Anthem GPS Assignments

BCBS Mid Level Enrollment

SHP Lunch ‘n’ Learn – Tomorrow, Sept 16th @ 12pm

As a reminder, the SHP Fall Lunch ‘n’ Learn series are continuing on with sessions scheduled over the next two weeks.

Please join us at 12:00 p.m. tomorrow, September 16, 2021, for an update on Georgia’s Managed Care market and developments; from what’s coming in 2021 from Medicare Advantage expansions to new Healthcare Exchange offerings to the conclusion of the PSHP/WellCare merger.  As the market continues to shift and narrow based on payer mergers; we’ll also talk longer-term strategy considerations to encourage competition in the market.

For the best experience, please join us using the link below:

And next week, September 22, 2020, we are thrilled to be joined by Department of Community Health Commissioner Frank Berry and Deputy Commissioner Blake Fulenwider. To join us for the physician session that will begin at 12:45 p.m. and will run approximately 45 minutes.

2021 is shaping up to be a big year for DCH, and we encourage you to join and hear from Commissioner Berry and Deputy Commissioner Fulenwider updates including the following topics:

  1. PSHP will officially take over WellCare’s Medicaid population in May 2021.
  2. DCH will re-procure the carriers for State Health Benefit Plan… is crucial in light of BCBSGA’s recent actions regarding physician contracts that DCH hears from physicians around the State how critical it will be to have additional options outside of BCBSGA & UHC.
  3. DCH will continue to pursue their Medicaid/Exchange plan waivers to expand Medicaid coverage in the State.

For the best experience, please join via the link below:

We look forward to talking with you then!

Hospital Pricing Transparency Webinar

Strategic Healthcare Partners in conjunction with Michele Madison at Morris, Manning & Martin present a review of the recent final rule issued by CMS requiring hospitals to release and publish pricing information BEFORE providing services.  We have heard many questions from providers looking for clarity and guidance.  We look to provide such education during an interactive lunch and learn session on September 30th at 12pEST.

Please join us by using this link:

MIPS Reporting Year 2020 Guidance Update

MIPS Reporting Year 2020 Guidance Update

After weeks of waiting, CMS has finally updated its MIPS guidance around the Reporting Year 2020 (RY2020). While CMS may make additional changes, this is the first major change for RY2020 we have seen thus far. For 2020, physicians and groups reporting for MIPS may submit an Extreme & Uncontrollable Circumstances Application to have some or all the MIPS categories reweighted to 0%. You must justify how COVID-19 has harmed your ability to achieve the category (or categories) you are asking to have reweighted.

Unlike the last-minute automatic reweight of RY2019, this will require effort on your organization’s part. You must provide examples showing:

  • How the pandemic prevented you from collecting necessary MIPS data for a category (or categories) (such as seeing patients only via telemedicine and no reliable method of collecting Quality Category data)
  • How the pandemic will prevent you from scoring a category (such as missing 3 months’ worth of Quality Category data)
  • How the pandemic impacted your normal business process that would affect your cost measures or other administrative claims measures (such as unable to send claims due to lack of enough billing staff)

SHP’s Recommendation

We recommend that if you intended to submit for RY2020 and you feel your data is complete enough to score well, continue to move forward with that plan. A reweight request of a category may result in a lower score than desired. A total reweight of MIPS will result in a score of 0, with penalty avoidance, but may harm your score on Physician Compare:

That said, if you do feel like a reweight will help your organization and you feel that you can justify the request to CMS, follow the instructions here:

As always, SHP is here to help you with your Quality Payment Program participation questions, and we will bring you timely information regarding any changes to the MIPS program for 2020 and beyond.

COVID-19 & MIPS Reporting Year 2020

Despite the on-going health crisis, the Quality Payment Program is still in full swing for Reporting Year 2020. MIPS practices, ACOs, and APMs are all expected to report their 2020 performance in Q1 2021. So far, CMS has only made some minor alterations to the QPP/MIPS program, largely focused on some “housekeeping-type” changes that will give QCDRs a little more breathing room. That said, CMS has indicated there will be changes coming to the MIPS program, but they have not given a clear timeline or any idea on what will change.

What Has Changed?

  • The biggest change has already come and gone, the data submission deadline for RY 2019 was moved to April 30. Those who did not submit data by that deadline were given a neutral adjustment instead of a penalty as the pandemic trigged an “Extreme and Uncontrollable Circumstances (E&UC) policy” exemption. Practices and providers that did submit will receive their adjustment accordingly.
  • New Improvement Activities (high-weight) for RY2020 were created that promotes participation in COVID-19 treatment clinical trials and reporting on COVID-19 data to a registry or data repository.
  • Extended the deadline for the QCDR measure & collection policies from Jan 1, 2021 to Jan 1, 2022. (This will require QCDRs to follow new rules for gathering more measures and sharing “unique” measures with others)
  • Extended the Call for Quality Measures & the submission of DVER to June 30

What Will Change?

At this point in time, it would be pure speculation as to what will change. The largest lobby groups have advocated for a 90-day reporting window for all four categories, another automatic trigger of the E&UC policy, a nation-wide “pause” on QPP, and other substantive changes. We won’t know until sometime this summer or even this fall if there will be any changes to this reporting year.

Therefore, it is our recommendation to proceed with your RY2020 plans and do not plan on making any modifications to your QPP behavior. Expect that while CMS will make changes, if you continue on the “there’s no change” path you will likely exceed their modified rules whenever they are released.

When CMS does release their changes, we will be here to post an update and provide education to help you understand and best navigate the rules.

Let’s Talk About How We Utilize the Department of Insurance

As the payer market in Georgia has consolidated through mergers/acquisitions; one of their key goals was increased efficiencies that they could leverage through size. Unfortunately, their provider partners have seen the exact opposite: consolidation has taken significant power out of the local state markets and placed it into national warehouses; whether that is claims appeals/provider loads and credentialing/etc. This national consolidation has slowed payer response and accountability to resolve issues.

Newly elected Insurance Commissioner Jim Beck recognizes that payers need increased accountability in Georgia and has, therefore, convened a stakeholders committee representing providers around the state; to identify the top four issues facing providers for the Insurance Commissioner to address with payer.

One of those key issues is provider credentialing and the typically slow processing of network loads; which is a statewide issue and a key focus of the complaints that they receive. It is evident that the payers in the state are not sufficiently meetings the challenges of provider credentialing.

Despite the universality of this issue, Commissioner Beck’s team shared that less than 10% of the overall complaints that their office receives are from physicians/hospitals. The DOI is simply not hearing from enough providers in this state to hold payers accountable to provider issues; in fact, medical complaints still represent the smallest percentage of insurance complaints received. Thus, the lack of complaints fails to trigger the additional scrutiny available from the DOI over payer activity.

The DOI’s resources are going to be devoted to the bulk of complaints that they received; therefore, SHP encourages our providers to ensure that they are utilizing the Department of Insurance complaint process. By appropriately reporting the myriad of payer issues, we believe that Commissioner Beck’s team will have a clearer picture of ongoing payer issues, thus direct their resources more actively in our assistance.

The DOI link is listed below in order to submit a Provider Complaint; including using the portal for electronic submission to DOI.

Top 10 Healthcare Headlines from 2018

From mergers and vertical integrations to changes in quality reporting and technology, Healthcare in America continues to evolve with an eye on access, quality, and efficiency. Here is a look back at some of the major headlines of 2018.


Amazon made another bold move into healthcare that went relatively unnoticed
Published by Healthcare Finance News

“Amazon expanded into the Medicaid market by announcing that it will offer beneficiaries a Prime membership of $5.99 a month, a discount of 54 percent. And while that revelation last week may not have raised quite as many eyebrows as the company’s blockbuster partnership with Berkshire Hathaway and JPMorgan Chase it holds the potential to have a major impact sooner.”

Click here to see the full article.


CMS Administrator Seema Verma calls for an end to physician fax machines by 2020
Published by Healthcare Finance News

“The Office of the National Coordinator for Health Information Technology and the Centers for Medicare and Medicaid Services are working together to realize a shared vision for a health ecosystem that sees the free flow of information between patient, provider and payer.”

Click here to view the full article.


Electronic Health Records Associated With Lower Hospital Mortality After Systems Have Time To Mature
Published by Health Affairs

“These findings suggest that national investment in hospital EHRs should yield improvements in mortality rates, but achieving them will take time.”

Click here to view the full article.


How Amazon, JPM, Berkshire could disrupt healthcare (or not)
Published by Healthcare Dive

“Merger mania in the healthcare space is indicative of industry wide uncertainty. The various stakeholders will try anything to better the system. Whether it’s CVS and Aetna, Amazon, Berkshire Hathaway and J.P. Morgan Chase, Ascension and Providence St. Joseph, they will use their scale, business savvy and technology, to drive costs out of the system — something CMS has struggled to do on its own.”

Click here to view the full article.


List: Healthgrades reveals America’s Best Hospitals for 2018
Published by Healthcare Finance News

“The Healthgrades analysis showed that those hospitals recognized as America’s Best did better than their peers in treating a core group of conditions that cause more than 80 percent of mortalities in areas evaluated, including heart attack, heart failure, pneumonia, respiratory failure, sepsis and stroke.”

Click here to view the full article.


More employers go direct to providers, sidestepping payers
Published by Healthcare Dive

“Some large employers are even sidestepping health insurers and contracting directly with providers. Another recent Willis Towers Watson survey found that only 6% of employers contract directly with providers now, but 22% are considering it for 2019.”

Click here to view the full article.


New Medicare Advantage rules hold big potential for pop health
Published by Healthcare Dive

“CMS issued a final rule in May giving MA plans more flexibility in determining the types of supplemental benefits they can offer chronically ill enrollees, including nonmedical benefits. The new policy, part of a broad 2019 Medicare payment rule, means plans like UnitedHealthcare and Humana aren’t harnessed to a set palette of supplemental benefits for members with chronic conditions, but can tailor them to the specific needs of individuals.”

Click here to view the full article.


Optum a step ahead in vertical integration frenzy
Published by Healthcare Dive

“UnitedHealth formed Optum by combining existing pharmacy and care delivery services within the company in 2011. Michael Weissel, Group EVP at Optum, told Healthcare Dive the company began by focusing on three core trends in the industry: data analytics, value-based care and consumerism.”

Click here to view the full article.


Rural And Nonrural Primary Care Physician Practices Increasingly Rely On Nurse Practitioners
Published by Health Affairs

“Overall, primary care practices are embracing interdisciplinary provider configurations, and including NPs as providers can strengthen health care delivery.”

Click here to view the full article.


See the list: CMS releases 2018 health plan star ratings
Published by Healthcare Finance News

“Star ratings measure the plan’s quality and performance in five categories: staying healthy screening tests, managing chronic conditions, member ratings of the health plan, member complaints and Medicare problems, and the handling of customer appeals.”

Click here to view the full article.